Tag cardiac

Frail patient with fungating tumour, severe cardiac disease

garychleung

PIG Meeting: 25th February 2021

79yo nursing home resident with an invasive, fungating BCC or SCC on his leg.

Background

  • Cardiac disease
    • PPM for AF/CHB
    • Admitted with CCF last year – found to have PHTN with TR and RV failure.
    • Improved, discharged to NH
  • T2DM diet controlled
  • RA
  • CKD
  • Low exercise tolerance 3.6METS on DASI

Issues

  • Profound SOB
    • Rpt TTE – relatively unchanged, mild improvement
  • Anaemia
    • Hb 117 -> 83, ? Cause. Nil obvious bleeding.
    • Likely contributing to his SOB

Discussion

  • Should he have surgery?
    • Overall life expectancy appears short
    • Surgeon, family and patient all keen to proceed
    • Essentially palliative surgery for pain/symptom relief
  • Opportunities for optimisation?
    • Cardiologist r/v suggests HF reasonably controlled
    • PRBC transfusion (likely as part of surgical admission due to logistic challenges with patients in NH)
  • Anaesthetic technique?
    • Skin grafting required so SAB likely ideal. Care with haemodynamic given pulmonary hypertension.

Elderly patient with severe heart disease for laparoscopic cholecystectomy

garychleung

PIG Meeting: 4th March 2021

73yo male booked for lap chole due to recurrent choledocholithiasis

Background

  • Choledocholithiasis – several admissions with sepsis requiring IV Abx and ERCPs
  • Cardiac disease
    • Missed STEMI 2019 – DES to LAD, LCx occluded, not amenable to PCI
    • Polymorphic VT arrest 2019 2 days post ERCP, hypokalaemic.
    • 2nd polymorphic VT arrest 2/7 later (K+ normal)
    • AICD placed, nil shocks since.
    • Bisoprolol and amiodarone
  • Paroxysmal AF – on dabigatran
  • GORD
  • Smoker
  • Ex tolerance 5 METS as per DASI

Issues

  • Cardiac status
    • TTE – EF 30-35%, stage I diastolic dysfx, mild MR, mild AR, e/o inferolateral RWMAs, biatrial moderate to severe enlargement.
    • Reviewed by cardiologist – Nil current e/o CCF, exercise tolerance only mildly limited

Discussion

  • Should he have surgery?
    • SORT score 5.4% risk of death
    • Severe cholangitis in this man carries a high risk of morbidity and mortality, as does emergency surgery.
    • While his risk of death with elective surgery is not insignificant it is likely the lower risk option.
  • Opportunities for optimisation?
    • Cardiologist r/v suggests HF reasonably controlled. Suggested ceasing Dabigatran 48h preop and switching to aspirin until resumption of anticoagulation.
  • Postoperative care location
    • >5% risk of perioperative mortality widely considered to represent ‘high risk’ however limited ICU bed spaces necessitates thoughtful rationing of resources.
    • Extended recovery (i.e. 4hr stay) is a useful option – observe for dysrythymias, replenish electrolytes as needed, support normal physiology then, provided no issues arise, discharge to normal ward.